Organizational Problem
Provide
Experts devote much time to charting and order entry accuracy. Charting involves maintaining electronic documentation, including compiling patient records data: their assessment, tests, prescribed treatment, progress, and other information. Computerized provider order entry (CPOE) is a system that allows sending requests necessary for the patient’s treatment, for example, ordering a test or medicine (Weiand et al., 2023).
CPOE and charting are usually part of the electronic health record (EHR) system, created to improve healthcare quality (Weiand et al., 2023). The problem of charting and order entry is a challenge associated with collecting and entering data since errors and inaccuracies are possible for various reasons, such as the inconvenience of the system, lack of personnel training, or failure of technology. Incomplete or erroneous documentation increases the risk to patients’ health and leads to medical errors or privacy breaches. Such problems can violate the principles of clinical ethics – autonomy, justice, beneficence, and nonmaleficence (Varkey, 2021).
Moreover, the Health Information Technology for Economic and Clinical Health (HITECH) Act supports the promotion of healthcare IT. It states that information exchange must be secure (The Office of the National Coordinator for Health Information Technology [ONC], 2019). The Health Insurance Portability and Accountability Act (HIPAA), in turn, protects patient privacy and confidentiality, which implies the obligation of professionals to ensure data security. Thus, problems in CPOE and charting can cause significant negative implications.
State
The problems of using CPOE and charting within the EHR present several challenges to institutions. Implementing systems requires the organization of training for employees and changing their study schedules. At the same time, medical specialists often report that charting can take a long time to interfere with their effectiveness (Tutty et al., 2019).
To save time, employees often copy data, which makes records too large, making it difficult to use them and increasing the risk of copying erroneous data (Tutty et al., 2019). The systems used may have technical issues – the order or information will not be received despite sending, the data of one patient may fall into the card of another, or not all functions for order and data entry work, which significantly complicates the work processes (Schulte & Fry, 2019). Moreover, problems with orders and records can confuse and lead to conflicts between departments.
Evidence-Based Support
Provide
The significance of problems related to CPOE and charting is supported by evidence. For example, the testimonies of specialists using such systems and data on their work prove that systems often slow down work and contribute to fatigue (Honavar, 2020). A study by Poulos et al. (2021) also revealed that about 40% of patients’ problems and diagnoses may go unnoticed due to inaccurate charting, raising the risk of errors.
Moreover, several cases of CPOE and charting errors have received publicity. The patient Annette Monachelli died in 2012 due to an aneurysm because the problem was not diagnosed: the test order to the laboratory was created but not transferred (Schulte & Fry, 2019). Consequently, CPOE and charting problems have significant negative implications for the patient’s treatment.
Address
Providers of health systems and their customers use various methods to solve the problems. For example, special standardized forms are introduced for orders to facilitate data entry and avoid errors (Weiand et al., 2023). Measures are being taken to create technical standards for working with CPOE and charting to improve system compatibility and efficiency (Tutty et al., 2019). Finally, EHR providers are constantly working to improve the functionality of systems, fixing errors that interfere with work.
Discuss
Various initiatives and quality standards are associated with the operation of systems, including CPOE and charting. ONC (2019) is a critical body that specializes in health IT. It is worth noting that the use of EHR is an initiative to improve the quality of services promoted by the HITECH Act (ONC, 2019). HIPAA protects patient privacy and sets data security standards (ONC, 2019). Safely implementing information systems, including CPOE and charting, within these standards aims to improve services and enhance patient safety and protection, which contributes to establishing a safety culture.
References
Honavar S. G. (2020). Electronic medical records – The good, the bad and the ugly. Indian Journal of Ophthalmology, 68(3), 417–418. Web.
Poulos, J., Zhu, L., & Shah, A. D. (2021). Data gaps in electronic health record (EHR) systems: An audit of problem list completeness during the COVID-19 pandemic. International Journal of Medical Informatics, 150, 1-6. Web.
Schulte, F., & Fry, E. (2019). Death by 1,000 clicks: Where electronic health records went wrong. KFF Health News. Web.
The Office of the National Coordinator for Health Information Technology. (2019). Laws, regulation, and policy. HealthIT.gov. Web.
Tutty, M. A., Carlasare, L. E., Lloyd, S., & Sinsky, C. A. (2019). The complex case of EHRs: Examining the factors impacting the EHR user experience. Journal of the American Medical Informatics Association, 26(7), 673-677. Web.
Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17-28. Web.
Weiand, D., Cullerton, C., Oxley, R., & Plummer, C. J. (2023). Impact of computerised provider order entry on the quality and quantity of clinical information included with investigation requests: An interrupted time series analysis. BMJ Open Quality, 12(1), 1-9. Web.